Insulin Prescribing Learning outcomes By the end of

Insulin Prescribing

Learning outcomes • By the end of the session you will be able to: – Explain the errors commonly associated with insulin prescribing – Outline the recommendations made by the NPSA alert on the safer use of insulin – Describe the steps you can put in place to make insulin prescribing safer – Demonstrate that you can review a prescription for insulin to identify any errors

Insulin facts 1 in 5 patients on an inpatient ward has diabetes • Around 4 in 10 inpatients with diabetes experience a medication error • Since 2003 insulin errors have led to over 17, 000 safety incidents including 6 deaths • Report showed that 62% insulin errors were around administration and prescribing

What do you know about insulin already?

So, what goes wrong?

Task • In groups of three or four make a list of the things you think can go wrong when prescribing and / or administering insulin.

Press images

The 4 R’s • • Right insulin Right time Right dose Right way

Right Insulin

The right insulin – the problem

The right insulin – the problem • Sometimes the name is in two parts e. g. Novomix® 30. This is a mixture of 30% fast-acting and 70% longer-acting insulin. The ‘ 30’ is a vital part of the name and is not the dose.

What can you do to make sure the right drug is prescribed? • Guidance • Check the name of the insulin with the patient. • Check the name in the British National Formulary (BNF). • The BNF is the official source of information about prescribing insulins. • State brand name when prescribing e. g. Lantus

The right dose – the problem • 100 units per ml • UK insulin for people is made in one strength – 100 units per ml also called U 100 insulin. This is not the dose!

The right dose – the problem • Units • Insulin doses are measured in units • Units can be abbreviated to u or iu

The right dose – the problem • However 4 units written as 4 u could become 40 units, or 4 iu could become 410 units with fatal results!

The right dose – the problem • Get the dose right

The right dose – the problem

What can you do to make sure the right dose is prescribed? • Never abbreviate “units” – always write it out in full e. g. 4 units • Let patients adjust their own dose if possible – they will usually be better at it than you. • Check the dose with the chart and the patient.

4 main types of insulin • • Rapid acting Short acting Intermediate acting Long acting

The right time

The right time • Rapid-acting insulin starts to work in minutes and brings the glucose down in 2 to 4 hours. • Modern analogue insulins can be given immediately before or straight after food. • Fast-acting insulins can also be used to bring down a high glucose level – take care not to cause hypoglycaemia. • Longer acting insulins are used for background action or to work later in the day. Their effects may last for days. Some of these insulins can be given without food because they work so slowly e. g. Lantus®, Levemir®.

The right time Type Onset Rapid Humalog Novorapid Apidra 5 – 15 mins 30 – 90 mins 3 -5 hours Short Actrapid Humulin S Insuman Rapid 30 – 60 mins 2 – 3 hours 5 -8 hours Intermediate Insulatard Humulin I Insuman basal 2 – 4 hours 4 – 10 hours 10 – 16 hours Long acting 2 – 4 hours Levemir Lantus Time to Duration of peak action 20 – 24 hours

Common regimes • Once daily – long acting • Twice daily – mix • Basal bolus – given four time a day to mimic normal physiology. Sort acting with meals PLUS intermediate once a day • IV insulin infusion “sliding scale” used in hospital

The right way • Insulin comes in the following containers/devices: • Vials • Cartridges for insulin pens • Preloaded insulin pens • Insulin pump systems • If insulin is given intramuscularly it works very quickly and can cause rapid hypoglycaemia. The effect is even faster intravenously and insulin is usually infused slowly rather than given as a bolus.

What can you do to make sure the insulin is administered in the right way? • Only give insulin in a syringe, pen or pump designed solely for insulin. Never use any other syringe or device. Prescribe the correct device for the patient. • Prescribe the correct route – usually SC • Patients on insulin usually know how to inject their own insulin – listen to the patient. In most cases, unless they are too ill or confused, the patient is the best person to inject their own insulin.

When would you use a sliding scale?

Sliding scale • Syringe of dextrose PLUS Actrapid® • Mainly used in the peri-operative period to tightly control CBG • If the patient is NBM • CBGs must be checked hourly and the rate will be dependent on the CBGs

Prescription review • Look at the prescription we have give you. • Highlight any errors you find – how would you rectify these?

• Objectives revisited: – Explain the errors commonly associated with insulin prescribing – Outline the recommendations made by the NPSA alert on the safer use of insulin – Describe the steps you can put in place to make insulin prescribing safer – Demonstrate that you can review a prescription for insulin to identify errors